Rudi Hoffman

Certified Financial Planner™

Cryonics Quote Request Form

"The cost of cryonic preservation may be affordable by funding the cost through a life insurance policy. For a monthly premium payment, you can create an instant source for paying for your suspension."

"This information will be used only for getting you the most appropriate and cost effective quote options. There is no cost or obligation to find out what your life insurance costs may be, and you may be surprised how affordable and attainable
this technology can be. Forms without complete information, including phone number, will probably be fed to the dogs. Also, please use the open form at the bottom to tell me anything about yourself that you think I might like or need to
know."

Cryonics Quote Request Form
To receive your free quote, please fill out the form below. All form information submitted will remain completely confidential.

Contact Information

First NameMiddle InitialLast NameE-mailPhone

Postal Address

Street AddressCityStateZip Code

Nicotine Usage

Nicotine Usage within 12 months
Yes
No

Nicotine Usage within 3 years
Yes
No

Birth Date

MonthDayYear

Sex
Male
Female
Marital Status
Married
Single

HeightWeight

U.S. Citizen Status

Are you a U.S. citizen
Yes
No
If not a U.S. citizen: What Country of CitizenshipVisa Type

Other

Preferred Cryonics Vendor
Alcor
Cryonics Institute
UnsureForm of Suspension
Neurosuspension
Full Body
UnsureOccupationHazardous SportsPre-existing Health IssuesDid either of your parents die from heart problems or cancer before age 60?
Yes
NoIn the past 3 years, have you traveled outside the US?
Yes
NoIn the last 5 years, have you had any moving violations?
Yes
NoHow did you hear about our web site?On a scale of one to ten, with ten being the highest interest, how would you quantify your intention to sign up for cryonics in the very near future?Have you viewed the 3 two minute videos on the cryonics signup process hereIf other, please tell us wherePlease provide details regarding "Yes" answers to health or moving violations above. Additionally, please write here with any other information you think I should know.

Securities America, Inc. is not affiliated with Alcor or Cryonics Insitute.

PRIVACY POLICY

It is understood that information provided on this site is confidential and will be maintained in a confidential and professional manner. It is understood this information is provided strictly for the purpose of obtaining a realistic and competitive life insurance or investment quotation, and this information will be kept confidential.